PERSONAL INFORMATION WORKSHEET AND CONSENT FORM You are required to complete and return this form before receiving ministry of deliverance and/or before assisting on deliverance teams Name: Date: Street address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail address: Marital status: Never married Married Separated Divorced Widowed Date of birth: / / Age: Gender: Male Female Have you accepted Jesus Christ as your Lord and Savior? Yes No Do you believe Jesus Christ was conceived of the Holy Spirit and born of the Virgin Mary? Yes No Do you believe Jesus Christ was crucified and died, was buried, rose again on the third day and is now seated at the right hand of the Father in heaven? Yes No Do you believe that the Blood of the Lamb is able to take away all sin? Yes No Church you attend: Have you ever fasted and prayed? Yes No Do you maintain a devotional life? (read the Word, pray regularly) Yes No Are you willing to submit yourself humbly to God? Yes No Will you be completely honest? Yes No Will you confess all known sins? Yes No Will you renounce any involvement with any area that may block your deliverance? Yes No These include: DOMINATING SPIRIT one s domination over another, i.e., husband over wife, friend, family member, parent. One person s power of control over another is in essence witchcraft. OCCULT or CULT INVOLVEMENT ouija boards, fortune tellers, palm readers, tarot cards, horoscopes, hypnosis, magic (white or black), séances, witchcraft, satanism, spiritism, false doctrines, heresies, cults, psychic, new age, rebellion (which is in essence witchcraft). HOMOSEXUALITY even if you have only been approached, but not actually involved in homosexual activity, it may be tormenting you. ABORTION Confessed as murder AN UNFORGIVING SPIRIT forgive all, hold no grudges (including forgiving yourself & God). Will to forgive. If this is not done, God cannot forgive or deliver you. Matthew 18:23-35. Where possible and practical, verbal apology and restitution are both necessary. Page 1
Describe your family background in the following areas: Parents Relationship with parents Parents vocation Self-image Social status (average, below, above) Brothers / sisters relationship Your vocation Describe your education and background in the following areas: School (high school, college, trade, etc.) Sports Special training Talents (hobbies) Military Service (branch) Page 2
Describe your medical history in the following areas: Diseases Extended fever Treatment for mental illness Describe your spiritual life in the following areas: Saved Baptized in water Baptized in the Holy Spirit Involved in ministry Daily devotions Tithe Page 3
LSD Uppers Downers Prescription Other Ouija Boards Séances Palm Readers Water Witching Tea Leaves Horoscopes Crystal Balls White Magic Other: Yoga AREAS OF INVOLVEMENT Check the box and put approximate dates or any brief explanation which you believe will assist the team leader Drugs Speed Marijuana Cocaine Crack Witchcraft Tarot Cards 8 Ball Warlock Witch Hypnosis Fortune-Teller Rebellion Black Magic Philosophical, Mental, Supernatural Levitation Clairvoyance Mind Control Mental Telepathy Voodoo spells Transcendental mediation Other: Food Sex Alcohol Drugs Other: Fear Addictions Medium Necromancer Karate-judo ESP Ventriloquism Psychics Smoking Diet pills Sleep aids Gambling Fear and Anxiety Anxiety Nightmares Doubt Stress Untrust Introvert Fear of man Page 4
Anger Rage Revenge Self pity AREAS OF INVOLVEMENT (Continued) Check the box and put approximate dates or any brief explanation which you believe will assist the team leader Excessive mourning Sorrow Pride Arrogance Boastful Bragging Idleness Overeating New Age Unsubmissive Argumentative Anger and Envy Envy Sorrow and Grief Extreme competition Insomnia Grief Pride and Control New Age Dictatorial Controlling Domineering Obstinate Contentious Unteachable Defensive Member of any Secret Society Knights Of Columbus Masonic Order Order Of The Arrow Rainbow Girls KKK Mormon Fraternity Sorority Eastern Star Job s Daughters Demolay Member of any Religious Cult Christian Scientist Scientology Moonies Buddhism The Way International Hari Krishna Jehovah s Witness Member of any Religious Group which denies the Atonement, Deity of Christ, Zen Satanism Muslim Unitarian Page 5
Alcohol Rock music AREAS OF INVOLVEMENT (Continued) Check the box and put approximate dates or any brief explanation which you believe will assist the team leader Molested / Molester Homosexual Fornication Adultery Pornography / x-rated movies / photographs Abortion Satan worship Raped / rapist Daydreaming Gossip Lying Cursing Stealing Prostitution Arthritis Asthma, hay fever, allergies Critical spirit Perfectionist Stubbornness Suicidal Mental illness Chronic ear problems Idolatry Love of money Superstitions Rejection Depression Near death experience (accident, medical, over-dose, etc.) Any generational information you d like to add Page 6
SUGGESTIONS ON HOW TO RECEIVE DELIVERANCE Is your problem demonic or is it the carnal nature? Suspect your need of deliverance only after you have gone through the normal channels of prayer, spiritual discipline, applying the Word, etc., and still don t have victory. SOME REASONS WHY DELIVERANCE MAY NOT BE REALIZED Lack of true repentance - repentance means a change of attitude and behavior Failure to confess sins - I John 1:9; James 5:16 Failure to forgive others - Mark 11:25, 26; Matthew 18:21-35 Failure to break with the occult - Acts 19:13-19 Unwillingness to be completely honest with God WHAT MAY I DO TO AID IN MY DELIVERANCE? Hate sin. YOU must mean business your part is important. Want complete deliverance of ALL spirits. Repent and confess your sins. Start renouncing the spirits, binding them yourself, before coming for deliverance Rid your surroundings, including your home, office, and car of all reminders including charms, books, records, videos, etc. and alter your lifestyle to avoid friends and places which serve as reminders. Pray and fast as much as you can but for at least one meal. Call on the Name of Jesus. Joel 2:32 HOW MAY I COOPERATE WITH THE PEOPLE PRAYING FOR ME? Be completely honest. Workers are unshockable and trustworthy. Humble yourself and acknowledge your need for help. Repent and confess your sins. Don t pray for yourself while the workers are praying for you. Words can hinder the exit of the demons. Don t hold back your physical reactions. The Greek word for spirit is PNEUMA. This is also the word for breath. Most evil spirits will be expelled via your mouth. On the other hand, there may be no physical reactions. WILL THESE DEMON SPIRITS TRY TO RETURN? According to Matthew 12:43-45 they will TRY to return. You must command them to leave you alone in the Name of Jesus. As Jesus did in the temptation, come back at them with the sword of the Spirit, the Word of God. Keep your deliverance by constantly praising the Lord. Keep your deliverance by putting on the whole armour of God. Ephesians 6:10-18 Keep your deliverance by daily applying Romans 12:1-2. Keep your deliverance by particularly guarding against resentments, hurts, and bitterness. Page 7
CONSENT FOR AN ADULT The information contained in these personal information worksheets will be used and studied only by the Deliverance Team. This information is confidential. I do hereby state and affirm that I have requested personal ministry from the Deliverance Team. I hereby give my consent for the Deliverance Team to administer said personal ministry to me. I release the Deliverance Team from any and all liability of every description that may arise as a result of this ministry. I release all members of the Deliverance Team including Bob Lucy and all staff members of Bob Lucy Ministries, paid and unpaid staffers, and all volunteer workers. Printed Name: Signature: Date: CONSENT FOR A MINOR The information contained in the personal information worksheets will be sued and studied only by the Deliverance Team. This information is confidential. Minor Child s Name: Date of Birth: Address of the Minor Child: I hereby state and affirm that I am the mother father legal guardian of the minor child named above and that I hereby give my consent for him/her to receive the personal ministry which he/she has requested from the Deliverance Team. I hereby give my consent for the Deliverance Team to administer said personal ministry to the above named Minor Child. I release the Deliverance Team from any and all liability of every description that may arise as a result of this ministry to the named Minor Child. I release all members of the Deliverance Team including Bob Lucy and all staff members of Bob Lucy Ministries, paid and unpaid staffers, and all volunteer workers. Printed Name: Mother Father Legal Guardian Signature: Date: